Navigating inflammation in IBD: a simplified approach to monitoring and treatment

The most significant risk to individuals living with IBD is inflammation.

Acute inflammatory flares are undeniably problematic, often necessitating urgent action such as hospitalisation for intensive therapy. Few would dispute the need for prompt intervention in such cases – typically involving oral or intravenous steroids, close monitoring, and, if necessary, surgical consultation.

New therapies are enabling more dynamic and responsive strategies.

Rapidly acting JAK inhibitors, for example, can effectively control inflammation early in a flare, potentially averting hospitalisation. However, realising the benefits of such interventions requires robust systems of care, from well-educated patients to specialised "flare" clinics with nursing and pharmacy support.

In acute situations, our aim is to control inflammation as swiftly and thoroughly as possible.

Yet, much of the time, inflammation is not severe. It may be mild or moderate, even "grumbling" in patients who feel otherwise well.

The disconnect between inflammation and symptoms poses the greatest challenge to effectively monitoring patients with IBD.

Cumulative inflammatory burden

Over time – weeks, months, years – individuals with chronic active intestinal inflammation may accumulate a significant cumulative inflammatory burden.

This chronic, uncontrolled inflammation may manifest subtly, with no apparent symptoms, or it may be poorly monitored and inadequately treated. Regardless, the long-term consequences can be profound:

• Disease progression

• Hospitalisation and surgery, possibly resulting in a stoma

• Cardiometabolic complications such as major adverse cardiac events and venous thromboembolism

• Neuropsychiatric issues including dementia, depression, and anxiety

• Increased risk of cancer, particularly colorectal cancer

• Poor quality of life and significant disability

However, despite these challenges, it's now 2024, and we have robust tools to manage inflammation.

The importance of monitoring

MONITOR, MONITOR, MONITOR, AND ACT ON THE RESULTS OF MONITORING.

The method of monitoring is less crucial than actually doing it and then acting on the results.

Detect inflammation. If inflammation is present, initiate, optimise, or switch therapy.

Far too many patients worldwide are inadequately monitored and under-treated. The reasons for this may vary, from lack of awareness to resource and time constraints. Nonetheless, many tools are available, including blood tests, faecal calprotectin, bowel ultrasound, cross-sectional imaging, and colonoscopy.

Our approach is straightforward: if CRP is >5 mg/L and/or faecal calprotectin is >250 mcg/g, then some action needs to be taken. This may entail further investigation, clinic review, or ongoing close monitoring, but typically involves optimised therapy or therapy adjustment.

The crucial point is that the entire multidisciplinary team understands this approach. With faecal calprotectin routinely assessed at every clinical interaction, the data are readily available as a dynamic measurement. Trends in faecal calprotectin (and CRP) over time offer powerful insights into an individual patient's inflammatory trajectory – providing valuable information about past events and future implications.

A note for patients

For patients in settings where such monitoring is lacking or inadequate, it's worth noting that most places will check faecal calprotectin if requested. And as a general guideline, if faecal calprotectin exceeds 250 mcg/g, it likely indicates active inflammation requiring attention.

Of course, faecal calprotectin is not a perfect test, and the ideal threshold is subject to debate. We are developing a dynamic clinical decision support tool based on longitudinal biomarker data to address much of this uncertainty.

This renewed focus on inflammation does not discount the importance of addressing other aspects of patient care. Holistic management, encompassing psychosocial, behavioral, and environmental factors, remains paramount.

However, at its core, the drugs available in 2024 are all anti-inflammatory medicines of some variety. While none are perfect, many are highly effective and increasingly targeted, with favourable safety profiles.

A note for fellow clinicians

To fellow clinicians: please don't persist with a drug that clearly isn't working out of fear of exacerbating the situation. Inertia can be just as harmful. While we continue to refine our understanding of therapy switching and sequencing, we have sufficient evidence to act decisively.

Consider the following scenarios that come easily to mind:

• A patient with Crohn's disease receiving adalimumab 40mg weekly, good drug levels, experiencing minimal symptoms but persistently elevated faecal calprotectin at 400-500 mcg/g with normal CRP – consider switching to a different biologic or JAK inhibitor.

• A patient with ulcerative colitis on 5-ASA, requiring a second course of steroids in a year – you should really consider initiating advanced therapy.

• A newly diagnosed patient with moderately active Crohn's disease – consider starting anti-TNF or another advanced therapy - do not delay.

Control the inflammation with a patient centred approach

Effective IBD management entails controlling intestinal inflammation while placing the individual patient at the center of decision-making.

And I haven’t even touched on treat-to-target, tight monitoring, or stride-2… until now 😊

A few years ago, Erik and i made this video on monitoring in IBD - the core points here are still valid